Role of Vitamin D Deficiency in Heart Disease

Cardiovascular disease (CVD) is a major cause of morbidity in the United States. People with CVD or at high risk of CVD need early detection and management of the disease (through counseling or medications).

So you may be wondering, what does vitamin D have to do with cardiovascular disease? First off, vitamin D is a fat-soluble vitamin that plays a hormonal role in skeletal health. Vitamin D does this by regulating calcium and phosphate metabolism. Furthermore, vitamin D deficiency has been identified as a potential risk factor for several diseases, including CVD and cancer. Research has shown evidence suggesting an association between low 25-hydroxyvitamin D levels and CVD.  Vitamin D deficiency has also been associated with atherosclerosis in coronary calcification as well as cardiovascular events like myocardial infarction, stroke, and CHF (congestive heart failure).

In conclusion, a vitamin D deficiency has been proven to have a connection with CVD, but the role of vitamin D supplementation for the management/treatment of the disease still needs to be established.

 

http://www.uspharmacist.com/content/d/pharmacy_focus/c/59395/

Saljoughian, Manouchehr. Role of Vitamin D Deficiency in Heart Disease. US Pharm. 2016;41(2):43-45.

Serum Vitamin D levels at admission predict the length of intensive care unit stay but not in-hospital mortality of critically ill surgical patients

Effects and benefits of vitamin D have been heavily studied, yet it seems as though we are only beginning to grasp just how influential vitamin D levels may be in certain medical situations.  A recent study sought to analyze the effects of vitamin D on length of stay in intensive care units, as well as in-hospital mortality, in patients who have recently had surgery.

The study was a prospective, cross-sectional, descriptive study that looked at 70 ICU patients over the course of a year at the Imam Khomeini Hospital in Iran. Basic demographic and health information was collected from the patients, as well as blood samples to determine serum levels. Of the 70 patients, 52 (74.3%) of them had serum vitamin D levels lower than 30 ng/mg. These patients had longer stays than patients with vitamin D levels greater than or equal to 30 ng/mL by roughly 3-4 days, and this was a statistically significant difference. The occurrence of hospital mortality, although higher in vitamin D deficient patients (25% vs. 22.2%), was not significantly different.

As hospital stays, especially in the ICU, require enormous amounts of money and resources, reducing the duration of stay would ease a great financial burden of the hospital, while also allowing patients to recover more quickly. I was very surprised by the findings of this study. We had recently learned about vitamin D and its transformation in the body, so I was surprised to find just how big of an impact it could have on length of hospital stays. I was aware that it was important for many things such as bone health and protecting the body from disease, but I would not have thought it could have such a significant impact on something like length of ICU hospital stays. I think that in the next few years we will continue to uncover many interesting effects and benefits of vitamin D, and we will hopefully be better educated as health professionals in suggesting vitamin D supplementation.

 

Alizadeh N, Khalili H, Mohammadi M, Abdullahi A. Serum Vitamin D levels at admission predict the length of intensive care unit stay but not in-hospital mortality of critically ill surgical patients. J Res Pharm Pract. 2015;4: 193–198.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4645131/

Vitamin D: No additional benefits in postmenopausal women

Many health professionals recommend that older postmenopausal women take a vitamin D supplement to help them avoid osteoporosis from developing and therefore preventing incidences of bone fractures, low bone density, etc. However, a recent study was conducted assessing different dosages of vitamin D supplements. Participants included postmenopausal women with no history of osteoporosis and were randomly either given high-dose cholecalciferol (50,000 IU) twice daily, low-dose cholecalciferol (800 IU) daily, or a daily placebo for one year. Patients in the high-dose group maintained vitamin D levels at 30 ng/mL or more by receiving extra doses if needed to reach this level. All groups of patients were counseled to consume between 600 mg and 1,400 mg of calcium every day.

The results showed that there were no significance differences in clinical outcomes between any of the groups, including the placebo group. This includes changes in bone mineral density, T-score, muscle mass and function, number of falls, physical activity, or functional status. Dr. Deborah Grady, MD, did acknowledge that the results may vary if the study is conducted for a longer period of time. However, it seems that there is no data to support the recommendation of keeping vitamin D levels at or above 30 ng/mL.


The take away from this study is that physicians’ recommendations may not always be valid. It is important for physicians and pharmacists to stay up to date on information such as this vitamin D study because it influences patient recommendations and health. I personally think it is important because keeping patients off of medications and supplements when possible is best – not only will they be happy to not have to take an additional pill every morning, but it also minimizes the chances for adverse effects with their drug therapy regimen. After reading this article, I am left wondering if there are any supplements that postmenopausal women can take in order to prevent onset of osteoporosis. If so, I would be interested to see if studies such as this one have been conducted to test their efficacy as well.

http://www.pharmacist.com/vitamin-d-no-additional-benefits-postmenopausal-women

Pucino F. “Vitamin D: No additional benefits in postmenopausal women.” Pharmacy Today. 22.1 (12 January 2016). 10. Web. 2 March 2016.

Serum anti-Mullerian hormone production is not correlated with seasonal fluctuations of vitamin D status in ovulatory or PCOS women

Polycystic ovarian syndrome (PCOS) is a disorder in women that is characterized by ovarian cysts from anovulation and is associated with hyperandrogenism and infertility. The most common symptoms of PCOS include polycystic ovaries, amenorrhea, hirsutism, obesity, insulin resistance, and infertility.

Anti-Mullerian hormone (AMH) is a glycoprotein produced by the ovary, and it plays an important role in maintaining ovarian reserve and modifying the follicles’ response to follicle stimulating hormone (FSH). Recently, there has been an increase in interest about the role that AMH plays in reproductive physiology. Many women of child-bearing age are now being tested for their AMH levels as a measure of both ovarian reserve and PCOS status.

Vitamin D’s role in reproduction has also sparked a lot of interest in recent years because many studies have come showing a correlation between vitamin D deficiency and many pregnancy-related disorders, including PCOS. Vitamin D is primarily produced by the skin in response to UV light exposure, and it can be supplemented in our diets. Earlier studies have shown that seasonal fluctuations in ovulation in countries of high latitude correspond to large seasonal fluctuations in serum vitamin D levels.

The purpose of this study was to clinically test if there is there a relationship between serum AMH levels and seasonal variations in serum vitamin D in women with ovulatory and polycystic ovary syndrome (PCOS). There was little research looking at the clinical relationship between AMH and Vitamin D before this study. The design was a retrospective cohort study that included 340 women aged less than 40 years, with 58 women having PCOS and 282 women having an ovulatory syndrome.  This data was collected as part of the subjects’ routine fertility assessment between January and December 2013 at a private fertility clinic in Adelaide, South Australia. The data collected from the subjects included age, BMI, cause of infertility, antral follicle counts (AFC), serum AMH and vitamin D levels, smoking status, and menstrual cycle length for women aged less than 40 years of age. Their serum AMH and vitamin D levels were sampled within the same 4-week period and were retrieved from a database. The hours of sunlight per day and daily UV index were extracted from a database at the South Australian Bureau of Meteorology which is located South Australia. The data analysis was done by analyzing serum vitamin D levels were against seasonal variation in sunlight and UV exposure and serum AMH levels.

The results of this study were that seasonal variations in serum vitamin D were observed between summer and winter, but serum AMH levels were NOT affected by the seasonal fluctuations in serum vitamin D in either the PCOS or ovulatory cohort. It was also found that serum vitamin D levels were not significantly related to the underlying cause of infertility . These results were contradictory to in vitro studies which have shown that vitamin D has the potential to modify AMH production.

I think the results of this study are interesting because previous evidence from in vitro studies would make one believe that serum vitamin D most likely has a direct effect on serum AMH. I think this study is a good example for health care providers and pharmacists that we can not always assume from related studies that drugs, hormones, disease states, etc. have direct effects on each other. It is important to conduct thorough research on topics that do not have direct evidence or findings because it is certainly not appropriate for health care providers and pharmacists to make assumptions based on related literature when treating patients’ disease states. As for the actual topics discussed in the study, I find it interesting that vitamin D deficiency has been previously found to effect problems associating with pregnancy and contraception. I would like to learn more about vitamin D’s role in pregnancy and how women with reproductive disorders are treated for problems with conceiving because I could potentially recommend women to take vitamin D supplements as a pharmacist to help them conceive.

My question posed to colleagues: Do you know anything about how vitamin D deficiency can be related to pregnancy disorders? What are your thoughts about the finding of this study in relation to the previous research completed about factors related to AMH and vitamin D?

Pearce, K, Gleeson, K, Tremellen, K. Serum anti-Mullerian hormone production is not correlated with seasonal fluctuations of vitamin D status in ovulatory or PCOS women. Hum Reprod. 2015;30:2171-2177.

Vitamin D Supplementation and Increased Risk of Falling

Are vitamins as important as we think they are? Should we take multiple vitamin supplements every day to improve health or is it more important to eat healthy well rounded diets? I would argue that eating healthy and getting natural vitamins from your food is much more important than taking supplements.

This article looks into vitamin D supplements to see if they really help to reduce the risk of fractures and falls or if they actually increase the risk. Steven R. Cummings, MD, the author of this article to a look at many randomized clinical trials as well as meta-analyses. One randomized clinical trial he discussed showed that women taking 500,000 IU of vitamin D increased the risk of fractures by 26 percent and the risk of falls by 15 percent. One interesting conclusion that Cummings came to is that vitamin D supplementation may have no effect on falls or fractures however you can reduce the risk of falls by about half by taking up and exercise program.

As future pharmacists we will have many patients who take over the counter supplements for one reason or another and it is very important that we know which supplements our patients are on. Although our patients think they are being healthy they could be creating drug therapy problems because many supplements interact with medication. Also it is important that we keep ourselves up to date with the literature because some vitamins may provide no help to our patients and it is our jobs to educate our patients.

Cummings SR, Kiel DP, Black DM. Vitamin D Supplementation and Increased Risk of Falling A Cautionary Tale of Vitamin Supplements Retold. JAMA Intern Med. 2016;176(2):171-172

JAMA Intern Med. 2016;176(2):171-172

Winter Months Call for Extra Vitamin D in Minority Youth

People, especially teenagers who have dark colored skin and who live in the Northern areas of the world, often lack normal levels of Vitamin D in their blood during the long winter months. This lack of Vitamin D is due to the fact that their skin’s pigmentation reduces their natural production of Vitamin D. Recent research has shown that changes in diet are still not getting these children enough vitamin D. So turning to prescription strength vitamin D is the most efficient way to get their levels up.

 

An 8 week study was conducted in 183 vitamin D deficient teenagers. These teenagers were given 3 different doses, one being prescription strength and the others being OTC strength. The results show that more than 80% of the patients that were taking the Rx strength dose were no longer Vitamin D deficient after the 8 week period. Furthermore, 60% of the patients on the OTC doses were still vitamin D deficient. This leads the researchers to believe that Vitamin D deficiency is a serious condition and something that requires prescription strength medication. The study also showed that both African American’s and Hispanics respond to this treatment in a similar manner. And that the heavier the patient is the more frequent dose they will need.

 

I found this article to be very interesting. I like the fact that the study was large and studied different minorities, it gave the study some depth. In addition, I think it is important to consider prescription strength vitamins like this. People are all too often looking for quick fixes for their ailments and immediately turn to prescription strength medications that are not naturally found in the body. I believe that prescribers should consider natural substances like this when treating patients as there are often fewer side effects associated.

 

Tabil HT, Ponnapakkam T, Gensure R, et al. Treatment of Vitamin D Deficiency in Predominantly Hispanic and Black Adolescents: A Randomized Clinical Trial. The Journal of Pediatrics. 2015.  

 

 

Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline

A major health concern for older populations is increased risk for falls. This is partly caused by reduced lower extremity function, prevention of which could save many injuries from occurring in older adults. Vitamin D has been thought to aid in lower extremity function and is especially believed to help with muscle weakness. To evaluate this, the researchers of this study conducted a double blind clinical trial to evaluate the effects of high-dose vitamin D in older adults. The study looked at 200 men and women with a low-trauma fall in the past year who were also 70 years and older. These 200 participants were separated into three study groups: one receiving 24,000 IU of vitamin D3 per month (normal dose), one receiving 60,000 IU of vitamin D3 per month, and one receiving 24,000 IU of vitamin D3 plus calcifediol per month. At the end of the study, the increase in 25-hydroxyvitamin D levels was evaluated for each group.

The results for the first group receiving 24,000 IU showed that the 25-hydroxyvitamin D levels increased by 11.7 ng/mL after 12 months. The second group receiving 60,000 IU increased its levels by 19.2 ng/mL. Finally, the third group receiving both the 24,000 IU and the calcifediol increased its 25-hydroxyvitamin D levels by 25.8 ng/mL after 12 months. The participants were also tested using the Short Physical Performance Battery (SPPB). This test assessed lower extremity function by evaluating walking speed, balance, and successive chair stands. When looking at the change in SPPB scores, it can be noted that there was no significant difference between the treatment groups. Further data collected from the study also evaluated the incidence of falls in the subjects. During the 12 month period of the study, 121 of the participants fell. The 60,000 IU group and the 24,000 IU group with calcifediol had significantly higher percentages of falls compared with the treatment group that only received the 24,000 IU of vitamin D3.

It was concluded that higher doses of vitamin D monthly do not provide benefit for the decline in lower extremity function. This was shown through the SPPB scores and the lack of improvement with higher doses. Also, high doses were shown to increase the number of falls in participants and, therefore, may be considered unsafe in older adults who have already experienced a fall.

I found this study to be interesting because we are often told how over the counter vitamins and herbals do not have much research behind them. I therefore chose to read this article to learn more information about vitamins. The study actually proved to me how little we seem to know about these supplements. The consensus on vitamin D that was used as the basis for this study was that it can improve muscle function. However, high doses of it actually seem to have done more harm than good. As a pharmacist, it is important to know this information when evaluating the medication regimen of an older adult. Doses of vitamin D should be monitored closely with someone who experiences falls, especially if they are taking other medications that may also contribute to more frequent falls.

Citation:

Bischoff-Ferrari H, Dawson-Hughes B, Orav J, et al. Monthly high-dose vitamin D treatment for the prevention of functional decline: a randomized clinical trial. JAMA Intern Med. 2016; 176(2): 175-183.

http://archinte.jamanetwork.com/article.aspx?articleid=2478897

Testing High-Dose Vitamin D Regimens to Reduce Falls in Elderly

In this study, researchers from Zurich sought out to determine the effectiveness of a high-dose Vitamin D regimen for decreasing falls related to lower-extremity decline. Those in the elderly population are especially susceptible to falls such as these because of decreased bone mass and strength, which can result in broken bones and other complications. Currently, Vitamin D is given to patients who present with Vitamin D deficiency and it has shown to curb falls in some. The thought behind this this study is that if low doses of Vitamin D are effective, higher doses of Vitamin D for those at risk of falls will be even more effective.

The study included 200 men and women above the age of 70 with history of falls. Over the course of the year, the participants were given either 24,000 IU of Vitamin D, 60,000 IU of Vitamin, or 24,000 IU of Vitamin D mixed with 300 micrograms of calcifediol. The 24,000 IU of Vitamin D represented the control group during this trial. At the end of the trial, it was discovered that the increased Vitamin dose did not reduce the chance of falls in the participants although it did generally keep the Vitamin D level higher than the control. I believe that this may affect the way that we approach Vitamins. Often, people believe that the more Vitamin that is taken in, the better for that individual. Having studies such as these that show that Vitamins can be useful, but only to a certain extent. Although this article is about Vitamin D specifically, it could lead to the more studies being completed about the inefficacy of Vitamins past a certain dose. This could have greater implications on the way that the public views Vitamins and could prevent individuals from taking high doses of Vitamins for practically no gain and potential risk. Do you think that Vitamins are currently overused?

Bischoff-Ferrari A et. al. Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline A Randomized Clinical Trial. JAMA Intern Med. Published Online January 4, 2016.doi:10.1001/jamainternmed.2015.71 48

http://archinte.jamanetwork.com.pitt.idm.oclc.org/article.aspx?articleid=2478897